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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> STANK REPAIR/RETROFIT __TANK LINING PING REPAIR <br /> EPA SITE 0 PROJECT CONTACT & TELEPHONE N <br /> F FACILITY NAME ®-' / � <br /> A ' �i .,�,/f a. %' �} PHONE <br /> C ADDRESS p� �! - <br /> _ jo- E - <br /> I 7 % 1 <br /> k f <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE _Q <br /> f <br /> j <br /> C CONTRACTOR NAME Al <br /> 0 ,p L (_/ir1 ! PHONE it <br /> N CONTRACTOR ADDRESS /'� /�, �l /� f04�� <br /> T t. �,Z'L)5 L(.off .I � I'���j,. CA LICIt) CLASS 6, IC1 i i <br /> R INSURER t WORK.COMP.;f &—/igen <br /> C OTHER INFORMATION <br /> T <br /> O PHONE A <br /> R <br /> PHONE A <br /> 11I1i1!!!11!!lI111l111I11l11i1 <br /> 34- <br /> TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> i 111 T1-ITI T <br /> APPROVED2APPRqVED WITH CONDITIONS) _ DISAPPROVED <br /> CONDITIONS) p <br /> J PLAN REVIEWERS NAME DATE ! <br /> Ilfi111111i111130 CL <br /> 111111 nniiillilililii 111iIi _ 11 Il 111111111 1111111111 11 111111111111111111111 illl!l1i1111ilill111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SEERVICEES. OWNER OR LICENSEE, AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFCRNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERF RMA CE A�OF�7E WORK FOR WHICH THIS PERMIT IS ISSUED, I. ALL EMPLOY PERSONS SUBJECT TO WORKER'SCOMPENSATICN LAWS OF CALINIA " <br /> APPLICANT'S SIGNATURE: Lw TIT6 ( old �(�u �T,C IE ! t <br /> LING INFORMATION:, <br /> icate the responsible party to be billed for additional PHS-EHO Staff time expended beyond permit payment coverage per tank If the <br /> y designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> biit-ing by signature and date bel <br /> e 1 <br /> _r-t <br /> I i ng address ' � l '' f� r t 1 p - tA <br /> s <br /> Phone Number <br /> CJ <br /> lature <br /> C 'Va4,) <br /> 3-t1O38 . <br /> 10 <br /> L � <br /> 7. <br /> a. or <br /> � .A,l XI <br /> r tv M—T <br /> vi <br /> � . <br /> :� <br />